1
|
Desprez D, Pierre L, Hittinger X, Babuty A, Sattler L, Ternisien C, Herb A, Trossaërt M, Gérout AC, Fouassier M, Wimmer J, Feugeas O, Drillaud N. Efficacy and safety of a recombinant von Willebrand factor treatment in acquired von Willebrand syndrome in case of bleeding and surgical procedures. Haemophilia 2024. [PMID: 39340334 DOI: 10.1111/hae.15098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 08/07/2024] [Accepted: 08/25/2024] [Indexed: 09/30/2024]
Abstract
INTRODUCTION Acquired von Willebrand syndrome (AVWS) is a rare haemorrhagic disorder. The prophylaxis and treatment of bleeding before surgery are complex. Since 2018, a new recombinant VWF (rVWF) concentrate that contains no factor VIII (FVIII) but a high amount of high molecular weight VWF multimers has been available in France. AIM To describe the real-world experience of using rVWF in non-surgical bleeding and surgical procedures in patients with AVWS. METHODS Fifteen bleeding episodes in seven patients and 16 surgeries in 10 patients were retrospectively analysed in t French haemostasis centres. RESULTS During bleeding, the median number of infusions was only 1 (range 1-27) with a median loading dose of 58 IU/kg (range 17-116) rVWF and a total median dose of 65 IU/kg (range 35-1488) rVWF. Bleeding control was rated markedly effective in 73% (11/15) of the cases and ineffective in 27% (4/15). During surgeries, the median number of infusions was 3 (range 1-8) with a preoperative loading dose of 60 IU/kg (range 23-118) rVWF and a total median dose of 123 IU/kg (range 31-542). The overall clinical efficacy was qualified as excellent, good and poor (ISTH criteria) in respectively 7 (43%), 6 (38%) and 3 (19%) procedures. There was no accumulation of VWF or FVIII during postoperative monitoring. No thromboembolic events nor adverse events were reported. CONCLUSION This French 'real-world' experience shows that rVWF could be of interest in the treatment and prophylaxis of bleeding in patients with AVWS, with no clinically significant safety concern.
Collapse
Affiliation(s)
- Dominique Desprez
- Haemophilia Treatment Centre, University Hospital of Strasbourg, Strasbourg, France
| | - Léa Pierre
- Haemophilia Treatment Centre, University Hospital of Strasbourg, Strasbourg, France
| | - Xavier Hittinger
- Haemophilia Treatment Centre, University Hospital of Nantes, Nantes, France
| | - Antoine Babuty
- Haemophilia Treatment Centre, University Hospital of Nantes, Nantes, France
| | - Laurent Sattler
- Haemophilia Treatment Centre, University Hospital of Strasbourg, Strasbourg, France
| | | | - Agathe Herb
- Haemophilia Treatment Centre, University Hospital of Strasbourg, Strasbourg, France
| | - Marc Trossaërt
- Haemophilia Treatment Centre, University Hospital of Nantes, Nantes, France
| | - Anne-Cécile Gérout
- Haemophilia Treatment Centre, University Hospital of Strasbourg, Strasbourg, France
| | - Marc Fouassier
- Haemophilia Treatment Centre, University Hospital of Nantes, Nantes, France
| | - Jordan Wimmer
- Haemophilia Treatment Centre, University Hospital of Strasbourg, Strasbourg, France
| | - Olivier Feugeas
- Haemophilia Treatment Centre, University Hospital of Strasbourg, Strasbourg, France
| | - Nicolas Drillaud
- Haemophilia Treatment Centre, University Hospital of Nantes, Nantes, France
| |
Collapse
|
2
|
Seidizadeh O, Eikenboom JCJ, Denis CV, Flood VH, James P, Lenting PJ, Baronciani L, O'Donnell JS, Lillicrap D, Peyvandi F. von Willebrand disease. Nat Rev Dis Primers 2024; 10:51. [PMID: 39054329 DOI: 10.1038/s41572-024-00536-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2024] [Indexed: 07/27/2024]
Abstract
von Willebrand disease (VWD) is the most common inherited bleeding disorder. The disorder is characterized by excessive mucocutaneous bleeding. The most common bleeding manifestations of this condition include nosebleeds, bruising, bleeding from minor wounds, menorrhagia or postpartum bleeding in women as well as bleeding after surgery. Other less frequent symptoms include gastrointestinal bleeding, haematomas or haemarthroses. VWD pathophysiology is complex and results from defects in von Willebrand factor (VWF) glycoprotein. Quantitative deficiencies are responsible for type 1 VWD with a partial decrease of VWF and type 3 with the complete absence of VWF. Qualitative abnormalities cause type 2 VWD, being further divided into types 2A, 2B, 2M and 2N. Although common, VWD is at risk of misdiagnosis, overdiagnosis and underdiagnosis owing to several factors, including complex diagnosis, variability of bleeding symptoms, presence of external variables (blood groups and other physiological modifiers such as exercise, thyroid hormones, oestrogens, and ageing), and lack of disease awareness among non-specialist health-care providers. Establishing the correct VWD diagnosis requires an array of specialized phenotypic assays and/or molecular genetic testing of the VWF gene. The management of bleeding includes increasing endogenous VWF levels with desmopressin or infusion of exogenous VWF concentrates (plasma-derived or recombinant). Fibrinolytic inhibitors, topical haemostatic agents and hormonal therapies are used as effective adjunctive measures.
Collapse
Affiliation(s)
- Omid Seidizadeh
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Jeroen C J Eikenboom
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Cécile V Denis
- Laboratory for Hemostasis, Inflammation & Thrombosis, Unité Mixte de Recherche 1176, Institut National de la Santé et de la Recherche Médicale, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Veronica H Flood
- Department of Paediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paula James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Peter J Lenting
- Laboratory for Hemostasis, Inflammation & Thrombosis, Unité Mixte de Recherche 1176, Institut National de la Santé et de la Recherche Médicale, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Luciano Baronciani
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.
| |
Collapse
|
3
|
Ichinose A, Osaki T, Souri M. Diagnosis and Treatment of Autoimmune Acquired Coagulation Factor Deficiencies: An Evidence-Based Review of Japanese Practice. Semin Thromb Hemost 2024. [PMID: 38866039 DOI: 10.1055/s-0044-1787188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
Among the acquired coagulation factor deficiencies, autoimmune coagulation factor deficiencies (AiCFD) are rare and result from autoantibody production against coagulation factors. In Japan, a nationwide survey on AiCFD has been conducted since 2009. Autoimmune factor XIII, factor VIII, von Willebrand factor, factor V, and factor X deficiencies (AiF13D, AiF8D, AiVWFD, AiF5D, and AiF10D, respectively) have been enacted as "designated intractable disease-282." The incidence of AiF8D, AiF13D, and AiF5D was 1.83, 0.044, and 0.038 per million people/year, respectively, whereas that of AiVWFD and AiF10D was not calculable owing to the small number of patients. AiF13D and AiF8D were often idiopathic, whereas AiVWFD was often associated with plasma cell neoplasms. Epistaxis was a characteristic symptom of AiVWFD, intramuscular bleeding was frequent in AiF13D and AiF8D, and subcutaneous bleeding (purpura) was frequent in AiF13D and AiF10D, although none were specific to any one disease. Differential diagnosis cannot be made based on bleeding symptoms alone; therefore, rapid and accurate testing is mandatory. Definitive diagnosis of AiCFD necessitates identifying the presence of coagulation factor "inhibitors" and/or "autoantibodies." Therefore, these tests should be performed upon unexplained severe acquired coagulation factor deficiencies. The mainstay of treatment for AiCFD was hemostatic therapy and autoantibody eradication therapy, which included the replacement of coagulation factors or "bypass" agents and administration of immunosuppressants. The rate of hemorrhagic death was high in AiF13D (13%), followed by AiF5D (7%) and Ai10D (5%); therefore, early diagnosis and optimal treatment are essential for AiCFDs. Given the unknown long-term prognosis, "intractable disease platform registries" have begun to accumulate in Japan.
Collapse
Affiliation(s)
- Akitada Ichinose
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan
- The Japanese Collaborative Research Group on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata University School of Medicine, Yamagata, Japan
| | - Tsukasa Osaki
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan
- The Japanese Collaborative Research Group on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata University School of Medicine, Yamagata, Japan
- Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Yamagata, Japan
| | - Masayoshi Souri
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan
- The Japanese Collaborative Research Group on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata University School of Medicine, Yamagata, Japan
- Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Yamagata, Japan
| |
Collapse
|
4
|
Waldron C, Ito S, Wang D, Allen C, Viswanathan G, Bona RD, Cuker A, Goshua G. Cost-effectiveness of prophylaxis with recombinant vs plasma-derived VWF in severe von Willebrand disease in the United States. Blood 2024; 143:2332-2335. [PMID: 38635764 DOI: 10.1182/blood.2024024209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/20/2024] Open
Abstract
ABSTRACT We evaluated the cost-effectiveness of prophylaxis with recombinant von Willebrand factor (rVWF) vs with plasma-derived von Willebrand factor (pdVWF) for patients with severe Von Willebrand disease. We found that rVWF is a cost-saving factor replacement compared with pdVWF across all willingness-to-pay thresholds in the United States.
Collapse
Affiliation(s)
| | - Satoko Ito
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | | | - Cecily Allen
- Division of Hematology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD
| | | | - Robert D Bona
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - George Goshua
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT
| |
Collapse
|
5
|
James P, Leebeek F, Casari C, Lillicrap D. Diagnosis and treatment of von Willebrand disease in 2024 and beyond. Haemophilia 2024; 30 Suppl 3:103-111. [PMID: 38481079 DOI: 10.1111/hae.14970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/05/2024] [Accepted: 02/08/2024] [Indexed: 04/22/2024]
Abstract
MANUSCRIPT BACKGROUND AND AIM The diagnosis and clinical care of patients with von Willebrand disease (VWD) has continued to evolve since the characterization of the von Willebrand factor (VWF) gene in 1985. This condition is almost certainly the most common inherited bleeding disorder, and the major symptomatic burden of the disease is experienced by females during their reproductive years. Diagnosis relies on the identification of a personal and family history of excessive mucocutaneous bleeding, and laboratory features consistent with quantitative and/or qualitative abnormalities of VWF. This review focuses on three aspects of VWD management, with current updates and a look into the future. MANUSCRIPT THEMES First, we will address the role of genetics in the diagnosis and possible therapies for VWD. With current technologies, VWD genetic diagnosis is usually confined to the confirmation of type 2 subtypes of the disease and type 3 VWD analysis for family planning. While type 3 VWD is a potential candidate for the application of gene therapy, no treatments are currently close to entering the clinic. Second, the peri-procedural management of patients with VWD remains an important element of care. The choice of product, its dose and schedule all require careful consideration depending upon the type and disruptive nature of the planned procedure. Lastly, in addition to gene therapy, several other novel therapeutic interventions are also being developed for bleeding and prophylaxis in VWD. These include a VWF aptamer interfering with VWF clearance and bioengineered forms of VWF.
Collapse
Affiliation(s)
- Paula James
- Departments of Medicine and Pathology and Molecular Medicine, Queen's University, Kingston, Canada
| | - Frank Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Caterina Casari
- University Paris-Saclay, INSERM, Hemostasis Inflammation Thrombosis HITH U1176, Le Kremlin-Bicêtre, France
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Canada
| |
Collapse
|
6
|
Leebeek FW, Castaman G, Marier JF, Özen G, Bhattacharya I, Zhang J, Wang S, Wang Y. Exposure-Response Relationship between VWF/FVIII Activity and Spontaneous Bleeding Events Following Recombinant VWF Prophylaxis in Severe VWD. TH OPEN 2024; 8:e243-e251. [PMID: 38938750 PMCID: PMC11211018 DOI: 10.1055/s-0044-1787815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 05/21/2024] [Indexed: 06/29/2024] Open
Abstract
Background Recombinant von Willebrand factor (rVWF, vonicog alfa, Takeda Pharmaceuticals USA) is indicated in adults diagnosed with von Willebrand disease (VWD). In this study, the exposure-response (ER) relationship between VWF activity (VWF:RCo) or factor VIII activity (FVIII:C) and spontaneous bleeding events (BEs) was evaluated in adults with severe VWD receiving rVWF prophylaxis for up to 1 year. Methods This secondary analysis included 23 patients receiving rVWF prophylaxis in the open-label, phase 3 prophylaxis trial (NCT02973087). Population pharmacokinetic (PK) and PK/pharmacodynamic (PD) models were used to characterize VWF activity and endogenous FVIII:C, and PK/PD simulations were linked to spontaneous BEs to develop an ER model. Results None of the five patients with VWD types 1 or 2A/B experienced spontaneous BEs. Five of 18 patients with VWD type 3 experienced ≥1 spontaneous BEs. An ER relationship was observed whereby higher VWF:RCo levels were associated with a numerically lower spontaneous BE risk ( p < 0.10). This relationship was independent of patients' pretrial VWF treatment. A statistically significant ER relationship was observed after accounting for relevant data (average ± standard error exposure estimate for VWF:RCo over 24 hours prior to the spontaneous BE: -0.043 ± 0.021, p = 0.041). The model-generated hazard ratio for a 10 IU/dL increment in the average exposure of VWF:RCo 24 hours before a spontaneous BE was 0.651 (95% confidence interval: 0.431-0.982). Conclusions This ER analysis suggests a causal association between VWF:RCo and spontaneous BEs, with an increase of VWF:RCo exposure leading to a decrease in spontaneous BE risk.
Collapse
Affiliation(s)
- Frank W.G. Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | | | - Gülden Özen
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, United States
| | | | - Jingmei Zhang
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, United States
| | - Scarlett Wang
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, United States
| | - Yi Wang
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, United States
| |
Collapse
|
7
|
Miesbach W, Halimeh S, Platokouki H, Podolak-Dawidziak M, Zdziarska J, Korczowski B, Chowdary P, Austin S, Millar C, Alamelu J, Rogosch T, Pabinger I. An open-label, multi-centre, post-marketing study to assess the efficacy and safety of a plasma-derived VWF/FVIII concentrate in patients with von Willebrand disease. Haemophilia 2024; 30:236-240. [PMID: 38030954 DOI: 10.1111/hae.14868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Wolfgang Miesbach
- Haemophilia Centre, Medical Clinic II, Institute of Transfusion Medicine, Goethe University Hospital, Frankfurt am Main, Germany
| | | | | | - Maria Podolak-Dawidziak
- Department of Haematology, Blood Neoplasms and Bone Marrow Transplantation, Medical University of Wroclaw, Wroclaw, Poland
| | - Joanna Zdziarska
- Department of Haematology, University Hospital, Jagiellonian University Medical College, Cracow, Poland
| | - Bartosz Korczowski
- Department of Pediatrics, Institute of Medical Sciences, Medical College, University of Rzeszow, Rzeszow, Poland
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Steve Austin
- St George's Healthcare NHS Trust Haemophilia Centre, London, UK
| | - Carolyn Millar
- Imperial College, London, UK and Imperial College Healthcare NHS Trust, London, UK
| | - Jayanthi Alamelu
- Children's Haemophilia Centre, Evelina London Children's Hospital, London, UK
| | | | | |
Collapse
|
8
|
Casari C, Leung J, James PD. New and emerging therapies for women, girls, and people with the potential to menstruate with VWD. Blood Adv 2023; 7:7501-7505. [PMID: 37967378 PMCID: PMC10758707 DOI: 10.1182/bloodadvances.2023010716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/24/2023] [Accepted: 11/09/2023] [Indexed: 11/17/2023] Open
Abstract
Innovation in therapies for patients with von Willebrand disease (VWD) has lagged far behind that for hemophilia, creating inequity in the bleeding disorder community. Although currently existing treatments of antifibrinolytics, desmopressin, and plasma-derived von Willebrand factor replacement are considered effective, multiple studies report poor quality of life in patients with VWD, especially those with heavy menstrual bleeding (HMB). This disconnect underscores the need for novel therapies that are safe and effective and that consider a patient's specific contraceptive and reproductive needs. Recombinant von Willebrand factor is the most recent new therapy for VWD; the data specific to women are reviewed. We also present emerging data on emicizumab for the treatment of VWD, BT200 (rondoraptivon pegol), generalized hemostatic therapies (VGA039 and HMB-011), as well as treatments based on nanotechnology (platelet-inspired nanoparticles and KB-V13A12). We are optimistic as we move toward pivotal clinical trials for these elegant and innovative treatments.
Collapse
Affiliation(s)
- Caterina Casari
- Université Paris-Saclay, INSERM, Hémostase Inflammation Thrombose HITH U1176, Le Kremlin-Bicêtre, France
| | - Jennifer Leung
- Department of Medicine, Queen’s University, Kingston, ON, Canada
| | - Paula D. James
- Department of Medicine, Queen’s University, Kingston, ON, Canada
| |
Collapse
|
9
|
Bhatti MQ, Gonzalez-Fernandez E, Bhatia K, Divani AA, Di Napoli M, Hinduja A, Datta YH. Neurological Complications Associated with Hereditary Bleeding Disorders. Curr Neurol Neurosci Rep 2023; 23:751-767. [PMID: 37864642 DOI: 10.1007/s11910-023-01313-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 10/23/2023]
Abstract
PURPOSE OF REVIEW Hereditary bleeding disorders may have a wide variety of clinical presentations ranging from mild mucosal and joint bleeding to severe central nervous system (CNS) bleeding, of which intracranial hemorrhage (ICH) is the most dreaded complication. In this review, we will discuss the pathophysiology of specific hereditary bleeding disorders, namely, hemophilia A, hemophilia B, and von Willebrand disease (vWD); their clinical manifestations with a particular emphasis on neurological complications; a brief overview of management strategies pertaining to neurological complications; and a review of literature guiding treatment strategies. RECENT FINDINGS ICH is the most significant cause of morbidity and mortality in patients with hemophilia. Adequate control of bleeding with the administration of specific factors or blood products, identification of risk factors for bleeding, and maintaining optimal coagulant activity are essential for appropriately managing CNS bleeding complications in these patients. The administration of specific recombinant factors is tailored to a patient's pharmacokinetics and steady-state levels. During acute bleeding episodes, initial factor activity should be maintained between 80 and 100%. Availability of monoclonal antibody Emicizumab has revolutionized prophylactic therapies in patients with hemophilia. Management of ICH in patients with vWD involves using plasma-derived factor concentrates, recombinant von Willebrand factor, and supportive antifibrinolytic agents individualized to the type and severity of vWD. Hemophilia and vWD are the most common hereditary bleeding disorders that can predispose patients to life-threatening CNS complications-intracranial bleeds, intraspinal bleeding, and peripheral nerve syndromes. Early care coordination with a hematologist can help develop an effective prophylactic regimen to avoid life-threatening bleeding complications in these patients. Further research is needed to evaluate using emicizumab as an on-demand treatment option for acute bleeding episodes in patients with hemophilia.
Collapse
Affiliation(s)
| | | | - Kunal Bhatia
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Afshin A Divani
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA.
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Sulmona, L'Aquila, Italy
| | - Archana Hinduja
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Yvonne H Datta
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
10
|
Ragni MV, Rothenberger SD, Feldman R, Nance D, Leavitt AD, Malec L, Kulkarni R, Sidonio R, Kraut E, Lasky J, Pruthi R, Angelini D, Philipp C, Hwang N, Wheeler AP, Seaman C, Machin N, Xavier F, Meyer M, Bellissimo D, Humphreys G, Smith KJ, Merricks EP, Nichols TC, Ivanco D, Vehec D, Koerbel G, Althouse AD. Recombinant von Willebrand factor and tranexamic acid for heavy menstrual bleeding in patients with mild and moderate von Willebrand disease in the USA (VWDMin): a phase 3, open-label, randomised, crossover trial. Lancet Haematol 2023; 10:e612-e623. [PMID: 37385272 PMCID: PMC10528809 DOI: 10.1016/s2352-3026(23)00119-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Heavy menstrual bleeding occurs in 80% of women with von Willebrand disease and is associated with iron deficiency and poor response to current therapies. International guidelines indicate low certainty regarding effectiveness of hormonal therapy and tranexamic acid. Although von Willebrand factor (VWF) concentrate is approved for bleeds, no prospective trials guide its use in heavy menstrual bleeding. We aimed to compare recombinant VWF with tranexamic acid for reducing heavy menstrual bleeding in patients with von Willebrand disease. METHODS VWDMin, a phase 3, open-label, randomised crossover trial, was done in 13 haemophilia treatment centres in the USA. Female patients aged 13-45 years with mild or moderate von Willebrand disease, defined as VWF ristocetin cofactor less than 0·50 IU/mL, and heavy menstrual bleeding, defined as a pictorial blood assessment chart (PBAC) score more than 100 in one of the past two cycles were eligible for enrolment. Participants were randomly assigned (1:1) to two consecutive cycles each of intravenous recombinant VWF, 40 IU/kg over 5-10 min on day 1, and oral tranexamic acid 1300 mg three times daily on days 1-5, the order determined by randomisation. The primary outcome was a 40-point reduction in PBAC score by day 5 after two cycles of treatment. Efficacy and safety were analysed in all patients with any post-baseline PBAC scores. The trial was stopped early due to slow recruitment on Feb 15, 2022, by a data safety monitoring board request, and was registered at ClinicalTrials.gov, NCT02606045. FINDINGS Between Feb 12, 2019, and Nov 16, 2021, 39 patients were enrolled, 36 of whom completed the trial (17 received recombinant VWF then tranexamic acid and 19 received tranexamic acid then recombinant VWF). At the time of this unplanned interim analysis (data cutoff Jan 27, 2022), median follow-up was 23·97 weeks (IQR 21·81-28·14). The primary endpoint was not met, neither treatment corrected PBAC score to the normal range. Median PBAC score was significantly lower after two cycles with tranexamic acid than with recombinant VWF (146 [95% CI 117-199] vs 213 [152-298]; adjusted mean treatment difference 46 [95% CI 2-90]; p=0·039). There were no serious adverse events or treatment-related deaths and no grade 3-4 adverse events. The most common grade 1-2 adverse events were mucosal bleeding (four [6%] patients during tranexamic acid treatment vs zero during recombinant VWF treatment) and other bleeding (four [6%] vs two [3%]). INTERPRETATION These interim data suggest that recombinant VWF is not superior to tranexamic acid in reducing heavy menstrual bleeding in patients with mild or moderate von Willebrand disease. These findings support discussion of treatment options for heavy menstrual bleeding with patients based on their preferences and lived experience. FUNDING National Heart Lung Blood Institute (National Institutes of Health).
Collapse
Affiliation(s)
- Margaret V Ragni
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA.
| | - Scott D Rothenberger
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert Feldman
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Lynn Malec
- Versiti Blood Research Institute, Milwaukee, WI, USA
| | | | | | - Eric Kraut
- The Ohio State University, Columbus, OH, USA
| | | | | | | | | | - Nina Hwang
- Center for Inherited Bleeding Disorders, Orange, CA, USA
| | | | - Craig Seaman
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
| | - Nicoletta Machin
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
| | - Frederico Xavier
- Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA; Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Meyer
- Vitalant Coagulation Laboratory, Pittsburgh, PA, USA
| | - Daniel Bellissimo
- Department of Pathology, Magee Women's Hospital Clinical Genomics Laboratory, Pittsburgh, PA, USA
| | - Gregory Humphreys
- Department of Pathology, Magee Women's Hospital Clinical Genomics Laboratory, Pittsburgh, PA, USA
| | - Kenneth J Smith
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Elizabeth P Merricks
- Department of Pathology and Laboratory Medicine and the UNC Blood Research Center, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Timothy C Nichols
- Department of Pathology and Laboratory Medicine and the UNC Blood Research Center, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Dana Ivanco
- Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
| | - Deborah Vehec
- Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
| | - Glory Koerbel
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andrew D Althouse
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
11
|
Franchini M, Focosi D. Targeting von Willebrand disease: the current status and future directions of management therapies. Expert Rev Hematol 2023; 16:871-878. [PMID: 37800892 DOI: 10.1080/17474086.2023.2268282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/04/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION von Willebrand disease (VWD) is the commonest inherited bleeding disorder, and is typically caused by deficits in the quantity or quality of von Willebrand factor (VWF). AREAS COVERED This review describes the main clinical, diagnostic, and therapeutic aspects of VWD, with particular attention to its management. In addition, standard and avant-garde replacement therapies based on the use of VWF are discussed. EXPERT OPINION The goal of treatment for VWD is to reverse the double hemostatic defect resulting from the abnormal or reduced expression of VWF and the concomitant factor VIII (FVIII) deficiency. Treatment consists of managing any bleeds and both short-term prophylaxis (i.e. for surgery or invasive procedures) and long-term prophylaxis. While desmopressin is suitable for most patients with type 1 VWD, VWF/FVIII concentrates are the treatment of choice for the other types of VWD. Beside plasma-derived VWF/FVIII concentrates, whose safety and efficacy have been demonstrated by several clinical trials, products containing only VWF, obtained by plasma fractionation and recombinant DNA technology, have become available and marketed more recently. The clinical use of these VWF-only products is particularly attractive in the setting of surgery and long-term prophylaxis, such as the prevention of recurrent gastrointestinal bleeding in cases of angiodysplasia.
Collapse
Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
| |
Collapse
|
12
|
Rauch A, Paris C, Daniel M, Branche J, Goudemand J, Susen S. Colon cancer surgery in von Willebrand disease type 3 setting triggering vascular abnormalities on bowel anastomosis. Res Pract Thromb Haemost 2023; 7:100277. [PMID: 37601018 PMCID: PMC10439390 DOI: 10.1016/j.rpth.2023.100277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/17/2023] [Accepted: 06/01/2023] [Indexed: 08/22/2023] Open
Abstract
Background von Willebrand disease (VWD) is associated with vascular malformations in the gastrointestinal tract. This complication, more frequent in VWD types 2A and 3, may be due to abnormal angiogenesis, but the precise mechanism is still unclear. Angiogenesis and inflammation are closely linked and can potentiate each other. Key Clinical Question Can colon inflammation in the setting of cancer surgery potentiate angiogenesis in the VWD setting? Clinical Approach A woman with VWD type 3 underwent partial colectomy twice for an adenocarcinoma. After managing the first surgery with a plasma-derived von Willebrand factor (VWF) concentrate (Wilfactin; LFB), refractory gastrointestinal bleeding occurred from neovessels on bowel anastomosis. After a multidisciplinary discussion, a second surgery was undertaken with a recombinant VWF concentrate (Veyvondi; Takeda Pharmaceuticals). Pathologic neovessels were again observed on the new anastomosis. Conclusion Colectomy was complicated twice by pathologic neovessels on bowel anastomosis in 2 distinct procedures managed either with plasma-derived VWF or with recombinant VWF.
Collapse
Affiliation(s)
- Antoine Rauch
- Hematology and Transfusion Department, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Camille Paris
- Hematology and Transfusion Department, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Mélanie Daniel
- Hematology and Transfusion Department, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Julien Branche
- Gastroenterology Department, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Jenny Goudemand
- Hematology and Transfusion Department, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Sophie Susen
- Hematology and Transfusion Department, Centre Hospitalier Universitaire de Lille, Lille, France
| |
Collapse
|
13
|
Bauer A, Friberg-Hietala S, Smania G, Wolfsegger M. Pharmacokinetic-Pharmacodynamic Comparison of Recombinant and Plasma-Derived von Willebrand Factor in Patients with von Willebrand Disease Type 3. J Blood Med 2023; 14:399-411. [PMID: 37332615 PMCID: PMC10276593 DOI: 10.2147/jbm.s395845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 05/26/2023] [Indexed: 06/20/2023] Open
Abstract
Background Recombinant von Willebrand factor (rVWF, vonicog alfa, Vonvendi/Veyvondi, Takeda Pharmaceuticals USA, Lexington, MA) and several plasma-derived VWF/factor VIII (pdVWF/FVIII) concentrates are available for treating bleeding episodes in patients with von Willebrand disease (VWD). Purpose To develop population pharmacokinetic (PK)/pharmacodynamic (PD) models that describe VWF:ristocetin cofactor (VWF:RCo) activity and its relationship with FVIII activity (FVIII:C) over time following intravenous administration of either rVWF or a pdVWF/FVIII concentrate (VWF:RCo/FVIII:C 2.4:1) in patients with VWD; to use the final PK/PD models for an in silico comparison of rVWF and pdVWF/FVIII. Methods The population PK model for rVWF was based on data from four clinical studies in which rVWF was administered to adult patients with VWD type 1, 2 or 3 (phase 1: NCT00816660; phase 3: NCT01410227 and NCT02283268) or severe hemophilia A (phase 1: EudraCT 2011-004314-42). The PK and PK/PD models for pdVWF/FVIII were based on data from the phase 1 study (NCT00816660) in patients with type 3 VWD who received either rVWF plus recombinant FVIII (rFVIII, octocog alfa, ADVATE®, Takeda Pharmaceuticals USA, Lexington, MA, USA) or pdVWF/FVIII. Results There was a marked difference in clearance following rVWF administration compared with pdVWF/FVIII in type 3 VWD, leading to a ~1.75 longer mean residence time (ie, persistence of VWF:RCo activity in the body) and half-life for rVWF versus pdVWF/FVIII. Simulations showed that following repeated administration of rVWF (50 IU/kg), a FVIII:C activity of >40 IU/dL can be maintained for the full 72 h dosing interval. Conclusion The slower elimination of VWF:RCo following rVWF administration results in a prolonged effect on FVIII turnover compared with pdVWF/FVIII administration.
Collapse
Affiliation(s)
- Alexander Bauer
- Statistical and Quantitative Sciences, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| | | | | | - Martin Wolfsegger
- Statistical and Quantitative Sciences, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| |
Collapse
|
14
|
Barbon E, Kawecki C, Marmier S, Sakkal A, Collaud F, Charles S, Ronzitti G, Casari C, Christophe OD, Denis CV, Lenting PJ, Mingozzi F. Development of a dual hybrid AAV vector for endothelial-targeted expression of von Willebrand factor. Gene Ther 2023; 30:245-254. [PMID: 33456057 PMCID: PMC10113149 DOI: 10.1038/s41434-020-00218-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 11/06/2020] [Accepted: 12/30/2020] [Indexed: 12/30/2022]
Abstract
Von Willebrand disease (VWD), the most common inherited bleeding disorder in humans, is caused by quantitative or qualitative defects in von Willebrand factor (VWF). VWD represents a potential target for gene therapy applications, as a single treatment could potentially result in a long-term correction of the disease. In recent years, several liver-directed gene therapy approaches have been exploited for VWD, but their efficacy was generally limited by the large size of the VWF transgene and the reduced hemostatic activity of the protein produced from hepatocytes. In this context, we aimed at developing a gene therapy strategy for gene delivery into endothelial cells, the natural site of biosynthesis of VWF. We optimized an endothelial-specific dual hybrid AAV vector, in which the large VWF cDNA was put under the control of an endothelial promoter and correctly reconstituted upon cell transduction by a combination of trans-splicing and homologous recombination mechanisms. In addition, we modified the AAV vector capsid by introducing an endothelial-targeting peptide to improve the efficiency for endothelial-directed gene transfer. This vector platform allowed the reconstitution of full-length VWF transgene both in vitro in human umbilical vein endothelial cells and in vivo in VWD mice, resulting in long-term expression of VWF.
Collapse
Affiliation(s)
- Elena Barbon
- Généthon, 91000, Evry, France
- Université Paris-Saclay, Université Evry, INSERM, Généthon, Integrare research unit UMR_S951, 91000, Evry, France
| | - Charlotte Kawecki
- Laboratory of Hemostasis, Inflammation and Thrombosis, Institut National de la Santé et de la Recherche Médicale UMR_1176, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
| | - Solenne Marmier
- Généthon, 91000, Evry, France
- Université Paris-Saclay, Université Evry, INSERM, Généthon, Integrare research unit UMR_S951, 91000, Evry, France
| | - Aboud Sakkal
- Généthon, 91000, Evry, France
- Université Paris-Saclay, Université Evry, INSERM, Généthon, Integrare research unit UMR_S951, 91000, Evry, France
| | - Fanny Collaud
- Généthon, 91000, Evry, France
- Université Paris-Saclay, Université Evry, INSERM, Généthon, Integrare research unit UMR_S951, 91000, Evry, France
| | - Severine Charles
- Généthon, 91000, Evry, France
- Université Paris-Saclay, Université Evry, INSERM, Généthon, Integrare research unit UMR_S951, 91000, Evry, France
| | - Giuseppe Ronzitti
- Généthon, 91000, Evry, France
- Université Paris-Saclay, Université Evry, INSERM, Généthon, Integrare research unit UMR_S951, 91000, Evry, France
| | - Caterina Casari
- Laboratory of Hemostasis, Inflammation and Thrombosis, Institut National de la Santé et de la Recherche Médicale UMR_1176, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
| | - Olivier D Christophe
- Laboratory of Hemostasis, Inflammation and Thrombosis, Institut National de la Santé et de la Recherche Médicale UMR_1176, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
| | - Cécile V Denis
- Laboratory of Hemostasis, Inflammation and Thrombosis, Institut National de la Santé et de la Recherche Médicale UMR_1176, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
| | - Peter J Lenting
- Laboratory of Hemostasis, Inflammation and Thrombosis, Institut National de la Santé et de la Recherche Médicale UMR_1176, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
| | - Federico Mingozzi
- Généthon, 91000, Evry, France.
- Université Paris-Saclay, Université Evry, INSERM, Généthon, Integrare research unit UMR_S951, 91000, Evry, France.
- Spark Therapeutics, Philadelphia, PA, 19103, USA.
| |
Collapse
|
15
|
Gritsch H, Schrenk G, Weinhappl N, Mellgård B, Ewenstein B, Turecek PL. Structure and Function of Recombinant versus Plasma-Derived von Willebrand Factor and Impact on Multimer Pharmacokinetics in von Willebrand Disease. J Blood Med 2022; 13:649-662. [PMID: 36405429 PMCID: PMC9673800 DOI: 10.2147/jbm.s377126] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 11/03/2022] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Recombinant von Willebrand factor (rVWF, vonicog alfa) is a purified VWF concentrate produced from Chinese hamster ovary cells. rVWF is not exposed to the VWF-cleaving protease ADAMTS13 and so is not subject to proteolytic degradation of large (L) and ultra-large (UL) VWF multimers by that enzyme. PURPOSE To compare the structure and function of rVWF with the human plasma-derived VWF [pdVWF] concentrates Haemate P®/Humate-P®, Voncento®, Wilate®/Eqwilate®, and Wilfactin®/Willfact®; to investigate the relationship between VWF multimeric pattern and VWF:ristocetin cofactor (VWF:RCo) activity through population pharmacokinetic (PK) modeling in patients with severe von Willebrand disease (VWD) treated with rVWF. METHODS Analyses included VWF:RCo activity, VWF:collagen-binding activity, VWF:platelet glycoprotein Ib receptor binding, factor VIII (FVIII) binding capacity, and VWF-mediated platelet adhesion under flow conditions. VWF multimeric structure was determined by agarose gel electrophoresis. Population PK models describing the activity-time profile of small, medium, and L/UL multimers following intravenous administration of rVWF in patients with severe VWD were developed. RESULTS Findings demonstrate that rVWF contains a non-degraded VWF multimer pattern including the UL multimers not present in pdVWF concentrates. rVWF displayed higher specific platelet-binding activity, and faster mediation of platelet adhesion to collagen under shear stress versus pdVWF concentrates. rVWF also demonstrated higher FVIII binding capacity than Haemate P®, Voncento® and Wilate®. Modeling provided evidence that VWF:RCo activity in patients with severe VWD treated with rVWF is associated with L/UL VWF multimers in the circulation. CONCLUSIONS Findings suggest that the L and UL multimers preserved in rVWF contribute to high biological activity and might be important for providing hemostatic efficacy.
Collapse
Affiliation(s)
- Herbert Gritsch
- Pharmaceutical Sciences, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| | - Gerald Schrenk
- Pharmaceutical Sciences, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| | - Nina Weinhappl
- Pharmaceutical Sciences, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| | - Björn Mellgård
- Rare Genetics and Hematology, Research & Development, Takeda Development Center Americas, Inc, Cambridge, MA, USA
| | - Bruce Ewenstein
- Rare Genetics and Hematology, Research & Development, Takeda Development Center Americas, Inc, Cambridge, MA, USA
| | - Peter L Turecek
- Department of Pharmaceutical Sciences, Division of Pharmacology, University of Vienna, Vienna, Austria
- Plasma Derived Therapies, Research & Development, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| |
Collapse
|
16
|
Leebeek FWG, Peyvandi F, Escobar M, Tiede A, Castaman G, Wang M, Wynn T, Baptista J, Wang Y, Zhang J, Mellgård B, Özen G. Recombinant von Willebrand factor prophylaxis in patients with severe von Willebrand disease: phase 3 study results. Blood 2022; 140:89-98. [PMID: 35439298 PMCID: PMC9283967 DOI: 10.1182/blood.2021014810] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 04/05/2022] [Indexed: 11/20/2022] Open
Abstract
International guidelines conditionally recommend long-term prophylaxis in patients with von Willebrand disease (VWD) and severe and frequent bleeding. As recombinant von Willebrand factor (rVWF; vonicog alfa) may reduce the frequency of treated spontaneous bleeding events (BEs), we investigated the efficacy and safety of rVWF prophylaxis in adults with severe VWD. Patients with BEs requiring VWF therapy in the past year (on-demand VWF therapy [prior on-demand group] or plasma-derived VWF prophylaxis [pdVWF; switch group]) were enrolled in a prospective, open-label, nonrandomized, phase 3 study. The planned duration of rVWF prophylaxis was 12 months; starting rVWF dose was 50 ± 10 VWF: ristocetin cofactor (VWF:RCo) IU/kg twice weekly (prior on-demand group) or based on prior pdVWF weekly dose/dosing frequency (switch group). The primary endpoint was annualized bleeding rate (ABR) of treated spontaneous BEs (sABR) during rVWF prophylaxis. Over the 12-month study period, treated sABR decreased by 91.5% on-study vs historical sABR in 13 patients in the prior on-demand group, and by 45.0% in 10 patients in the switch group (model-based analysis ratio, 0.085; 95% confidence interval [CI], 0.021-0.346 and 0.550; 95% CI, 0.086-3.523, respectively). No treated spontaneous BEs were recorded in 84.6% (11/13) and 70.0% (7/10) of patients, respectively. The safety profile of rVWF was consistent with the previously established profile, with no new adverse drug reactions identified. Findings suggest that rVWF prophylaxis can reduce treated spontaneous BEs in patients previously receiving on-demand VWF therapy and maintains at least the same level of hemostatic control in patients who switch from prophylaxis with pdVWF to rVWF, with a favorable safety profile. This trial was registered at www.clinicaltrials.gov (#NCT02973087) and www.clinicaltrialsregister.eu (#EudraCT 2016-001478-14).
Collapse
Affiliation(s)
- Frank W G Leebeek
- Department of Hematology, University Medical Center, Erasmus MC, Rotterdam, The Netherlands
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Miguel Escobar
- University of Texas Health Science Center at Houston, Houston, TX
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Michael Wang
- Hemophilia and Thrombosis Center, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Tung Wynn
- Department of Pediatrics, University of Florida, Gainesville, FL
| | | | - Yi Wang
- Takeda Development Center Americas, Inc, Cambridge, MA
| | - Jingmei Zhang
- Takeda Development Center Americas, Inc, Cambridge, MA
| | | | - Gülden Özen
- Takeda Development Center Americas, Inc, Cambridge, MA
| |
Collapse
|
17
|
Ichinose A, Osaki T, Souri M, Favaloro EJ. A Review of Autoimmune Acquired von Willebrand Factor Deficiency in Japan. Semin Thromb Hemost 2022; 48:911-925. [PMID: 35803264 DOI: 10.1055/s-0042-1749088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
von Willebrand factor (VWF) forms high-molecular-weight multimers and plays an essential role in hemostasis, and thus its deficiency leads to bleeding symptoms. Acquired von Willebrand syndrome (AVWS) is rare, but potentially underdiagnosed, and develops in various underlying disorders. AVWS caused by anti-VWF autoantibodies is a rare subcategory of AVWS that can also be referred to as autoimmune VWF deficiency (AiVWFD). We performed a search of patients with autoimmune coagulation factor deficiencies in our nationwide survey in Japan. Among these, suspected cases of AiVWFD were extremely few, with only 11 case consultations in the last 10 years. Of these, three and five were respectively positive for anti-VWF autoantibodies (anti-VWF-Ab) and VWF inhibitor (VWF-inh). We also performed an extensive literature search of other cases from Japan, and in total, 40 cases were finally identified to have AiVWFD, with mean age of 55.0 years. Most underlying disorders were lympho- or myeloproliferative diseases, followed by autoimmune diseases. The major bleeding sites were subcutaneous and mucosal, the bleeding severity was moderate, and there were no hemorrhagic deaths. Bleeding time was prolonged; factor VIII activity, VWF antigen, and VWF activity were decreased, and high-molecular-weight VWF multimers were absent or decreased. These are similar to the common abnormal laboratory findings observed among general AVWS cases. Hemostatic therapy often involved VWF concentrates and vasopressin, and antibody eradication therapy often included corticosteroids and achieved remission. Notably, of all cases, 68% had anti-VWF-Abs, and 83% of anti-VWF-Ab-positive patients were also VWF-inh positive. To accumulate precise clinical information on AiVWFD, it is necessary to verify and improve the measurement methods for both anti-VWF-Ab and anti-VWF-inh. These findings from Japan should be confirmed in other geographic localities.
Collapse
Affiliation(s)
- Akitada Ichinose
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan.,The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan
| | - Tsukasa Osaki
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan.,The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan.,Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Iida-Nishi, Yamagata, Japan
| | - Masayoshi Souri
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan.,The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan.,Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Iida-Nishi, Yamagata, Japan
| | - Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead, New South Wales, Australia.,Faculty of Science and Health, Charles Sturt University, Wagga Wagga, New South Wales, Australia
| |
Collapse
|
18
|
Correlation Analysis of DNA Methylation in the von Willebrand Factor Promoter Region and the Risk of Unexplained Recurrent Hemophilia: Systematic Review and Meta-Analysis. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:3977289. [PMID: 35711531 PMCID: PMC9187466 DOI: 10.1155/2022/3977289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 05/09/2022] [Indexed: 01/19/2023]
Abstract
This study systematically reviewed the effect of DNA methylation in the promoter region of the coagulation factor vWF gene on the risk of unexplained recurrent hemophilia. PubMed, Medline, Web of Science, and other computers were used to search the database, and the statistical randomized controlled trials of coagulation factor vWF in the risk analysis of unknown recurrent hemophilia were collected. The Cochrane systematic evaluation method was used to evaluate the quality of the included kinds of literature, and Revman5 software was used to sort out and analyze the kinds of literature. Meta-analysis showed that there was a statistical difference between the experimental group and the control group in case fatality rate (OR = 1.76, 95% CI (1.29, 2.39), P=0.0003, I2 = 0%, Z = 3.58), adverse events (OR = 2.38, 95% CI (1.65, 3.45), P < 0.00001, I2 = 0%, Z = 4.60), incidence of joint hemorrhage (OR = 2.52, 95% CI (1.62, 3.91), P < 0.00001, I2 = 0%, Z = 4.12), incidence of subcutaneous stasis (OR = 1.76, 95% CI (1.26, 2.45), P=0.0009, I2 = 5%, Z = 3.33), and hematoma volume (OR = 1.78, 95% CI (1.32, 2.40), P=0.0001, I2 = 23%, Z = 3.80). DNA methylation in the promoter region of the coagulation factor vWF gene was significantly associated with the risk of unexplained recurrent hemophilia. Whether demethylation can improve the bleeding index of patients with recurrent hemophilia remains to be further explored.
Collapse
|
19
|
Farrugia A, Smit C, Buzzi A. The legacy of haemophilia: Memories and reflections from three survivors. Haemophilia 2022; 28:872-884. [PMID: 35588502 PMCID: PMC9542818 DOI: 10.1111/hae.14587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/04/2022] [Accepted: 05/01/2022] [Indexed: 11/28/2022]
Abstract
Following the publication of a book of personal memories by one of us (CS1,2), we have attempted to synthesis our joint memories of three ageing men, born in the era preceding universal access to treatment, in an attempt to describe our experience, our challenges and our reflections on the development of therapies, which have ensured that our experience of growing up with haemophilia in the 1950s and 1960s has not been mirrored by the current generation of patients. We describe our upbringing in different parts of Europe in health care systems which, while of varying standards, were all unable to offer the kind of care which developed after the development of specific therapies. We assess the effect of the contamination of these therapies by blood‐borne pathogens on our own development, and the development of our communities around us. In addition, we reflect on the lessons learnt, sometimes painfully, by our generation of people with haemophilia and how some of these enabled us to overcome substantial hurdles, survive and build productive lives. Finally, we survey the development of therapies in the past 20 years, and offer some reflections on how our experience can be integrated in a realistic expectation of what the future holds for our community, in our own affluent societies and in countries less advantaged economically. We hope that our thoughts may contribute to continued progress in the field of haemophilia care.
Collapse
Affiliation(s)
- Albert Farrugia
- Faculty of Medicine and Medical Sciences, University of Western Australia, Perth, Australia
| | - Cees Smit
- Department of Epidemiology, Leiden University Medical Center (LUMC), Hoofddorp, The Netherlands
| | | |
Collapse
|
20
|
Castaman G, Borchiellini A, Coppola A, Cultrera D, Marino R, Federici AB, Giuffrida AC, Marchesini E, Molinari AC, Maria SS, Zanon E. Use of the von Willebrand factor concentrate with low factor VIII content to manage patients with inherited von Willebrand disease requiring surgical or secondary long-term prophylaxis: An expert opinion paper from an Italian panel. Eur J Haematol 2022; 109:121-128. [PMID: 35531770 DOI: 10.1111/ejh.13785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The present review aims to summarize the state-of-the-art von Willebrand disease (VWD) treatment focusing on specific clinical settings (obstetrics, surgery, long-term prophylaxis and comorbidities) as well as on the use of a Von Willebrand factor (VWF) concentrate with low FVIII content. METHODS Literature research and case reports. RESULTS AND CONCLUSIONS Considering that patients affected by VWD have an intact ability to synthesize FVIII, in order to avoid excessive levels of FVIII, a highly purified plasma VWF concentrate with low FVIII content could be particularly useful in those patients and clinical circumstances at high thrombotic risk as well as for long-term prophylaxis. When deciding the optimal therapeutic strategy, physicians should take into account both the patient's history and the differences among available concentrates according to the clinical situations requiring treatment.
Collapse
Affiliation(s)
- Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Alessandra Borchiellini
- RRC Thrombosis & Haemophilia Centre, AOU Città della Salute e della Scienza - Molinette Hospital, Turin, Italy
| | - Antonio Coppola
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, Parma, Italy
| | - Dorina Cultrera
- Department of Haematology, Haemophilia Regional Reference Centre, University Hospital of Catania, Catania, Italy
| | - Renato Marino
- Haemophilia and Thrombosis Centre, Policlinico Giovanni XXIII, Bari, Italy
| | - Augusto B Federici
- Division of Haematology and Transfusion Medicine, L. Sacco University Hospital and Department of Oncology and Haematology Oncology, University of Milan, Milan, Italy
| | | | - Emanuela Marchesini
- Department of Vascular and Emergency Medicine, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Angelo Claudio Molinari
- Regional Reference Centre for Hemorrhagic Diseases, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Siboni Simona Maria
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Milan, Italy
| | - Ezio Zanon
- Haemophilia Center, General Medicine, Department of Medicine, University of Padua Medical School, Padua, Italy
| |
Collapse
|
21
|
Weyand AC, Sidonio RF, Sholzberg M. Health issues in women and girls affected by haemophilia with a focus on nomenclature, heavy menstrual bleeding, and musculoskeletal issues. Haemophilia 2022; 28 Suppl 4:18-25. [PMID: 35521724 PMCID: PMC9321707 DOI: 10.1111/hae.14535] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/24/2022] [Accepted: 02/24/2022] [Indexed: 12/26/2022]
Abstract
Introduction Women and girls affected by haemophilia, including haemophilia carriers (WGH) are at risk of bleeding symptoms that may go unrecognized, including heavy menstrual bleeding (HMB) and musculoskeletal bleeding. Terminology continues to evolve. Aim To describe the current recommendations for nomenclature surrounding WGH, and the current understanding of HMB, iron deficiency, and musculoskeletal complaints in these patients. Methods Literature was reviewed and summarized. Results With regards to nomenclature, women with factor levels less than 50% should be classified as having haemophilia, while carriers with normal levels should be characterized accordingly to symptomatology. HMB and resultant iron deficiency are common among WGH, have a multitude of downstream effects, and maybe overlooked due to stigma around menstruation. Musculoskeletal bleeding and resultant joint changes are increasingly recognized in this population but do not necessarily correlate with factor levels. Conclusion Although progress has been made in the care of WGH, much work remains to further improve their care.
Collapse
Affiliation(s)
- Angela C Weyand
- Department of Pediatrics, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Robert F Sidonio
- Department of Pediatrics, Division of Hematology/Oncology, Emory University, Atlanta, Georgia, USA
| | - Michelle Sholzberg
- Departments of Medicine, and Laboratory Medicine and Pathobiology, St. Michael's Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
22
|
Li X, Lu Z. Role of von Willebrand factor in the angiogenesis of lung adenocarcinoma (Review). Oncol Lett 2022; 23:198. [PMID: 35572495 PMCID: PMC9100484 DOI: 10.3892/ol.2022.13319] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/19/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Xin Li
- Department of Oncology, Affiliated Hospital of Weifang Medical College, Weifang, Shandong 261053, P.R. China
| | - Zhong Lu
- Department of Oncology, Affiliated Hospital of Weifang Medical College, Weifang, Shandong 261053, P.R. China
| |
Collapse
|
23
|
Samii A, Norouzi M, Ahmadi A, Dorgalaleh A. Gastrointestinal Bleeding in Congenital Bleeding Disorders. Semin Thromb Hemost 2022; 48:529-541. [PMID: 35021252 DOI: 10.1055/s-0041-1741571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Gastrointestinal bleeding (GIB) is serious, intractable, and potentially life-threatening condition. There is considerable heterogeneity in GIB phenotypes among congenital bleeding disorders (CBDs), making GIB difficult to manage. Although GIB is rarely encountered in CBDs, its severity in some patients makes the need for a comprehensive and precise assessment of underlying factors and management approaches imperative. Initial evaluation of GIB begins with assessment of hematological status; GIB should be ruled out in patients with chronic anemia, and in presentations that include hematemesis, hematochezia, or melena. High-risk patients with recurrent GIB require urgent interventions such as replacement therapy for treatment of coagulation factor deficiency (CFD). However, the best management strategy for CFD-related bleeding remains controversial. While several investigations have identified CBDs as potential risk factors for GIB, research has focused on assessing the risks for individual factor deficiencies and other CBDs. This review highlights recent findings on the prevalence, management strategies, and alternative therapies of GIB related to CFDs, and platelet disorders.
Collapse
Affiliation(s)
- Amir Samii
- Department of Hematology and Blood Transfusion, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mahshaad Norouzi
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Abbas Ahmadi
- Cellular and Molecular Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Akbar Dorgalaleh
- Department of Hematology and Blood Transfusion, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
24
|
Franchini M, Seidizadeh O, Mannucci PM. Prophylactic management of patients with von Willebrand disease. Ther Adv Hematol 2022; 12:20406207211064064. [PMID: 34987743 PMCID: PMC8721401 DOI: 10.1177/20406207211064064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/15/2021] [Indexed: 01/19/2023] Open
Abstract
Von Willebrand disease, the most common inherited bleeding disorder that affects both males and females, is due to quantitative or qualitative defects of the multimeric glycoprotein von Willebrand factor, which cause mucous membrane bleeding but also soft tissue bleeding owing to the secondary deficiency of factor VIII. The aim of treatment is to correct this dual defect of hemostasis. In addition to the episodic management of bleeding episodes, therapy includes their short- or long-term prevention. Short-term prophylaxis is mainly warranted in order to provide effective hemostatic coverage to patients undergoing surgery or invasive procedures and to affected women at the time of delivery or during menstruations associated with excessive bleeding. The aim of long-term prophylaxis is to prevent bleeding in particular categories of patients at increased risk of frequent and spontaneous bleeding in the joints, nose, and gastrointestinal tract.
Collapse
Affiliation(s)
- Massimo Franchini
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, 46100 Mantova, Italy
| | - Omid Seidizadeh
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Milan, Italy
| | - Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Milan, Italy
| |
Collapse
|
25
|
[Interpretation of Chinese guideline on the diagnosis and management of von Willebrand disease (2022)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:13-15. [PMID: 35231986 PMCID: PMC8980658 DOI: 10.3760/cma.j.issn.0253-2727.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
26
|
Seth R, McKinnon TAJ, Zhang XF. Contribution of the von Willebrand factor/ADAMTS13 imbalance to COVID-19 coagulopathy. Am J Physiol Heart Circ Physiol 2022; 322:H87-H93. [PMID: 34890277 PMCID: PMC8714251 DOI: 10.1152/ajpheart.00204.2021] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The 2019 coronavirus disease (COVID-19) is the disease caused by SARS-CoV-2 infection. Although this infection has been shown to affect the respiratory system, a high incidence of thrombotic events has been observed in severe cases of COVID-19 and in a significant portion of COVID-19 nonsurvivors. Although prior literature has reported on both the coagulopathy and hypercoagulability of COVID-19, the specifics of coagulation have not been fully investigated. Observations of microthrombosis in patients with COVID-19 have brought attention to potential inflammatory endothelial injury. Von Willebrand factor (VWF) and its protease, A disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13), play an important homeostatic role in responding to endothelial injury. This report provides an overview of the literature investigating the role the VWF/ADAMTS13 axis may have in COVID-19 thrombotic events and suggests potential therapeutic strategies to prevent the progression of coagulopathy in patients with COVID-19.
Collapse
Affiliation(s)
- Ryan Seth
- Department of Bioengineering, Lehigh University, Bethlehem, Pennsylvania
| | - Thomas A J McKinnon
- Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, London, United Kingdom
| | - X Frank Zhang
- Department of Bioengineering, Lehigh University, Bethlehem, Pennsylvania
| |
Collapse
|
27
|
Alqahtany FS, ALBackr HB, Aldakhil LO, Alharbi AA, Alqahtani NA, Algahtani FH. Hemostatic profile detailing in apparent VWD cases: A cross sectional study. Saudi J Biol Sci 2021; 28:6701-6704. [PMID: 34866968 PMCID: PMC8626209 DOI: 10.1016/j.sjbs.2021.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/10/2021] [Accepted: 07/12/2021] [Indexed: 11/02/2022] Open
Abstract
The von willebrand disease (vWD) accounts to be one of the most common hereditary bleeding ailment that amounts its incidence to almost 1.5% of normal population. It is mostly associated with a defect in primary hemostasis as well as secondary defect in coagulation factor VIII as diagnosis of vwd happened to be challenging with earlier diagnostic criteria's. Testing Vwd in menorrhagia patients was not at ease. A cross-sectional study was conducted in female patients who have visited obstetrics and gynecology clinic at King Saud University Medical City (KSUMC), Riyadh, Saudi Arabia. The inclusion criteria consist of adult female patients between 16 and 45 years old with menorrhagia. A sample of 45 patients were screened and selected for the above-mentioned study. The SPSS Statistical analysis package was performed to analyze the data's. The fisher's exact test was conducted to compare the demographic variables. The independent samples t-test was conducted to compare the means of subjects. The P value of ≤0.05 considered as statistically significant. The cases manifested with a history of bleeding during periods stretching from 7 to 90 days. The vWD was reported in 6.6 % (n = 3) women out of the total 45 patients. The vWF: Ac mean ± SD (51.4 ± 6.3) and vWF: Ag Mean ± SD (93 ± 67) were significantly lesser in vWD patients with that of non-vWD (98.7 ± 22.6) vs (116 ± 42.4) (p = 0.027) (p = 0.032) respectively. WBC, ESR, MCV, MCH, Hemoglobin, PLT count, INR, PT, APTT and FVIII showed no significant difference among the groups (p > 0.05).
Collapse
Affiliation(s)
- Fatmah S Alqahtany
- Hematopathology Unit, Department of Pathology, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Hanan B ALBackr
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Lateefa O Aldakhil
- Department of Obstetrics and Gynecology, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah A Alharbi
- College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nawaf Abdullah Alqahtani
- College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Farjah H Algahtani
- Division of Oncology/Hematology, Department of Medicine, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
28
|
McNicholas A, Sharma N, Rowe EL, Benotti SA, Braverman BR, Normandin PA. Adolescent With von Willebrand Disease Type 3 Spontaneous Abdominal Hemorrhage. J Emerg Nurs 2021; 47:661-668. [PMID: 34275529 DOI: 10.1016/j.jen.2021.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 10/20/2022]
Abstract
An adolescent female classified as unstable with a spontaneous abdominal hemorrhage was transferred to a level 1 pediatric trauma tertiary emergency department. Pertinent medical history included von Willebrand disease type 3, menorrhagia, and obesity. Preparation before patient arrival included mobilization of multidisciplinary medical team experts in hematology, pharmacy, blood bank, radiology, and nursing who provided lifesaving interventions. The administration of factor products, blood products, interventional radiology, emergent hepatic angiography, and embolization coordination resulted in a successful outcome. After an 18-day intensive hospital course, the patient returned home close to her baseline health status.
Collapse
|
29
|
Pastuschek J, Bär C, Göhner C, Budde U, Leidenmuehler P, Groten T, Schleußner E, Markert UR. Ex vivo human placental transfer study on recombinant Von Willebrand factor (rVWF). Placenta 2021; 111:69-75. [PMID: 34171523 DOI: 10.1016/j.placenta.2021.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 04/29/2021] [Accepted: 05/31/2021] [Indexed: 10/21/2022]
Abstract
Deficiency or mutation of von Willebrand factor (VWF) leads to a coagulation disorder (von Willebrand disease; VWD) which requires a lifelong therapy. For avoiding maternal complications treatment may be necessary also in pregnancy, but placental transfer to the fetus might impact its coagulation system and evoke undesired side effects. As VWF is a very large molecule it may be assumed that it does not pass the placental barrier. To prove this hypothesis the materno-fetal transfer of recombinant VWF (rVWF) has been analyzed ex vivo in a total of 21 valid dual side placenta perfusions. Three groups of five placentas each have been perfused with physiological and up to ten-fold increased concentrations of rVWF for 2 h. Six placentas have been used for control perfusions. A series of different control parameters has been assessed for documentation of intactness and functionality of the placenta and the perfusion system. In not a single analysis, independent of time and concentration, rVWF was detected in the fetal circuit. In the maternal circuit VWF concentration decreased slightly during perfusion. These results demonstrate that recombinant VWF does not pass the human placenta.
Collapse
Affiliation(s)
- J Pastuschek
- Placenta Lab, Department of Obstetrics, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - C Bär
- Placenta Lab, Department of Obstetrics, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - C Göhner
- Placenta Lab, Department of Obstetrics, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - U Budde
- Medilys Laborgesellschaft MbH, Paul-Ehrlich-Str. 1, 22763, Hamburg, Germany
| | | | - T Groten
- Placenta Lab, Department of Obstetrics, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - E Schleußner
- Placenta Lab, Department of Obstetrics, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - U R Markert
- Placenta Lab, Department of Obstetrics, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany.
| |
Collapse
|
30
|
Population pharmacokinetics of the von Willebrand factor-factor VIII interaction in patients with von Willebrand disease. Blood Adv 2021; 5:1513-1522. [PMID: 33683340 DOI: 10.1182/bloodadvances.2020003891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/21/2021] [Indexed: 01/19/2023] Open
Abstract
Recent studies have reported that patients with von Willebrand disease treated perioperatively with a von Willebrand factor (VWF)/factor VIII (FVIII) concentrate with a ratio of 2.4:1 (Humate P/Haemate P) often present with VWF and/or FVIII levels outside of prespecified target levels necessary to prevent bleeding. Pharmacokinetic (PK)-guided dosing may resolve this problem. As clinical guidelines increasingly recommend aiming for certain target levels of both VWF and FVIII, application of an integrated population PK model describing both VWF activity (VWF:Act) and FVIII levels may improve dosing and quality of care. In total, 695 VWF:Act and 894 FVIII level measurements from 118 patients (174 surgeries) who were treated perioperatively with the VWF/FVIII concentrate were used to develop this population PK model using nonlinear mixed-effects modeling. VWF:Act and FVIII levels were analyzed simultaneously using a turnover model. The protective effect of VWF:Act on FVIII clearance was described with an inhibitory maximum effect function. An average perioperative VWF:Act level of 1.23 IU/mL decreased FVIII clearance from 460 mL/h to 264 mL/h, and increased FVIII half-life from 6.6 to 11.4 hours. Clearly, in the presence of VWF, FVIII clearance decreased with a concomitant increase of FVIII half-life, clarifying the higher FVIII levels observed after repetitive dosing with this concentrate. VWF:Act and FVIII levels during perioperative treatment were described adequately by this newly developed integrated population PK model. Clinical application of this model may facilitate more accurate targeting of VWF:Act and FVIII levels during perioperative treatment with this specific VWF/FVIII concentrate (Humate P/Haemate P).
Collapse
|
31
|
Recombinant vs plasma-derived von Willebrand factor to prevent postpartum hemorrhage in von Willebrand disease. Blood Adv 2021; 4:3234-3238. [PMID: 32692849 DOI: 10.1182/bloodadvances.2020002046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/25/2020] [Indexed: 01/03/2023] Open
Abstract
von Willebrand disease (VWD) is a congenital bleeding disorder characterized by deficient or defective von Willebrand factor (VWF). Among women with VWD, postpartum hemorrhage (PPH) is common. Treatment options at delivery include plasma-derived VWF (pdVWF) and recombinant VWF (rVWF). However, limited data are available regarding their efficacy. We conducted a retrospective observational study comparing PPH in women with VWD treated at the Hemophilia Center of Western Pennsylvania between 1 February 2017 and 31 January 2018 with either rVWF or pdVWF. We compared postpartum outcomes, including PPH frequency and estimated blood loss (EBL) at delivery. There were a total of 12 deliveries, 7 vaginal and 5 cesarean. At delivery and for 3 days postpartum, 6 women received 80 IU/kg of rVWF and 6 received 80 IU/kg of pdVWF, based on prepregnancy weight, insurance, and/or patient choice. Treatment groups had similar demographics, including median age (32.0 vs 27.0 years; P = .075), bleeding scores (3.0 vs 3.5; P = .734), and prepregnancy body mass index (29.0 vs 29.2 kg/m2; P = .691). PPH occurred in 3 (25.0%) of 12 deliveries, with no difference by treatment group (2 of 6 rVWF vs 1 of 6 pdVWF; P = 1.000) and no difference in EBL by treatment group (685 vs 462 mL; P = .384) or delivery type (vaginal, P = .722 vs cesarean, P = .531). In summary, PPH occurred in one-fourth of the deliveries in women with VWD, despite a higher dose (80 IU/kg) of rVWF or pdVWF. Future trials are needed to develop and assess novel strategies to prevent PPH in VWD.
Collapse
|
32
|
Castaman G, Linari S. Obstacles to Early Diagnosis and Treatment of Inherited von Willebrand Disease: Current Perspectives. J Blood Med 2021; 12:165-175. [PMID: 33790680 PMCID: PMC7997550 DOI: 10.2147/jbm.s232758] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/15/2021] [Indexed: 01/02/2023] Open
Abstract
Von Willebrand disease (VWD), the most common inherited bleeding disorder, is highly heterogeneous, and its early diagnosis may be difficult, especially for mild cases and in qualitative von Willebrand factor (VWF) defects. Appropriate VWD diagnosis requires the combination of personal and/or family history of bleeding and abnormal VWF laboratory testing. The use of bleeding assessment tools has been helpful in standardizing bleeding history collection and quantification of bleeding symptoms to select patients who may benefit of further hemostatic testing. Type 1 and 3 VWD which represent quantitative VWD variants are relatively easy to diagnose. The diagnosis of type 2 VWD requires multiple assessments to evaluate the effects induced by the responsible abnormality on the heterogeneous functions of VWF. Sensitive and reproducible tests are needed to evaluate different VWF activities, starting from measuring VWF-platelet interaction. In the recent years, several increasingly sensitive, rapid and automated assays have been developed, but they are not widely available so far. Genetic testing for VWD diagnosis is not a common practice because VWF gene is very large and highly polymorphic and therefore it is used only in specific cases. It is evident that the early and correct VWD diagnosis allows optimal management of bleeding and situations at risk. Tranexamic acid, desmopressin, replacement therapy with plasma-derived concentrates with a variable content of VWF and FVIII, or the new recombinant VWF are the different therapeutic options available. Careful VWD classification guides treatment because desmopressin is widely used in type 1 while replacement therapy is the cornerstone of treatment for type 2 and 3 variants.
Collapse
Affiliation(s)
- Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
| | - Silvia Linari
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
| |
Collapse
|
33
|
Seidizadeh O, Peyvandi F, Mannucci PM. Von Willebrand disease type 2N: An update. J Thromb Haemost 2021; 19:909-916. [PMID: 33497541 DOI: 10.1111/jth.15247] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 12/18/2022]
Abstract
Quantitative or qualitative defects of von Willebrand factor (VWF) are responsible for the most common inherited bleeding disorder, von Willebrand disease (VWD). Type 2N VWD is an uncommon recessive disorder that results from gene mutations located in the region coding for the binding site of VWF for factor VIII (FVIII). This narrative review describes the pathophysiology, diagnostic procedures and treatment as well as the molecular biology of type 2N VWD. Although other VWF-dependent functions like binding to platelets and collagen are preserved, FVIII plasma levels are low due to the rapid clearance of this moiety in the absence or reduction of its binding to VWF. The diagnosis of type 2N should be considered in patients with low FVIII coagulant activity (FVIII:C) and disproportionally higher VWF antigen, especially when they present with an autosomal recessive pattern of inheritance. Because an accurate diagnosis is essential for genetic counseling and optimal treatment, type 2N must be distinguished from mild/moderate hemophilia A and its carrier state. This differential diagnosis can be obtained by using the laboratory assay of the FVIII binding capacity of VWF (VWF:FVIIIB) or analysis of the FVIII binding site on the VWF gene.
Collapse
Affiliation(s)
- Omid Seidizadeh
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| |
Collapse
|
34
|
O'Donnell JS. Toward Personalized Treatment for Patients with Low von Willebrand Factor and Quantitative von Willebrand Disease. Semin Thromb Hemost 2021; 47:192-200. [PMID: 33636750 DOI: 10.1055/s-0041-1722864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The biological mechanisms involved in the pathogenesis of type 2 and type 3 von Willebrand disease (VWD) have been studied extensively. In contrast, although accounting for the majority of VWD cases, the pathobiology underlying partial quantitative VWD has remained somewhat elusive. However, important insights have been attained following several recent cohort studies that have investigated mechanisms in patients with type 1 VWD and low von Willebrand factor (VWF), respectively. These studies have demonstrated that reduced plasma VWF levels may result from either (1) decreased VWF biosynthesis and/or secretion in endothelial cells and (2) pathological increased VWF clearance. In addition, it has become clear that some patients with only mild to moderate reductions in plasma VWF levels in the 30 to 50 IU/dL range may have significant bleeding phenotypes. Importantly in these low VWF patients, bleeding risk fails to correlate with plasma VWF levels and inheritance is typically independent of the VWF gene. Although plasma VWF levels may increase to > 50 IU/dL with progressive aging or pregnancy in these subjects, emerging data suggest that this apparent normalization in VWF levels does not necessarily equate to a complete correction in bleeding phenotype in patients with partial quantitative VWD. In this review, these recent advances in our understanding of quantitative VWD pathogenesis are discussed. Furthermore, the translational implications of these emerging findings are considered, particularly with respect to designing personalized treatment plans for VWD patients undergoing elective procedures.
Collapse
Affiliation(s)
- James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Coagulation Centre, St. James's Hospital, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital at Crumlin, Dublin, Ireland
| |
Collapse
|
35
|
Sattler L, Feugeas O, Crimizade U, Hess S, Grunebaum L, Desprez D. Use of recombinant Von Willebrand factor during transcatheter aortic valve replacement in a patient with acquired von Willebrand syndrome. Transfus Med 2021; 31:142-144. [PMID: 33626595 DOI: 10.1111/tme.12765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/15/2021] [Accepted: 02/15/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Laurent Sattler
- Laboratoire d'Hématologie, Unité Hémostase, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Olivier Feugeas
- Centre de Ressource et Compétence des Maladies Hémorragiques Constitutionnelles, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Ulun Crimizade
- Service de Cardiologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Sébastien Hess
- Service de Cardiologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Lélia Grunebaum
- Laboratoire d'Hématologie, Unité Hémostase, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Dominique Desprez
- Centre de Ressource et Compétence des Maladies Hémorragiques Constitutionnelles, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| |
Collapse
|
36
|
Rawley O, Lillicrap D. Functional Roles of the von Willebrand Factor Propeptide. Hamostaseologie 2021; 41:63-68. [PMID: 33588457 DOI: 10.1055/a-1334-8002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The primary polypeptide sequence of von Willebrand factor (VWF) includes an N-terminal 741-amino acid VWF propeptide (VWFpp). In cells expressing VWF, the VWFpp performs two critical functions. In the Golgi, VWFpp mediates the intermolecular disulfide linkages that generate high-molecular-weight VWF multimers. Subsequently, the VWFpp, which is proteolytically cleaved from mature VWF by furin, functions to generate the endothelial storage organelles (Weibel-Palade bodies) in which VWF and a distinct collection of proteins are stored, and from where they undergo regulated secretion from the endothelium. The VWFpp is secreted from endothelial cells as dimers and circulates in plasma with at least some of the dimers associating with a noncovalent manner with the D'D3 domain of mature VWF. The VWFpp has a half-life of 2 to 3 hours in plasma, but to date no extracellular function has been determined for the molecule. Nevertheless, its large size and several biologically interesting structural features (two sets of vicinal cysteines and an RGD sequence) suggest that there may be roles that the VWFpp plays in hemostasis or associated physiological processes such as angiogenesis or wound repair.
Collapse
Affiliation(s)
- Orla Rawley
- Department of Pathology and Molecular Medicine, Richardson Laboratory, Queen's University, Kingston, Ontario, Canada
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Richardson Laboratory, Queen's University, Kingston, Ontario, Canada
| |
Collapse
|
37
|
Desprez D, Drillaud N, Flaujac C, Volot F, Pan-Petesch B, Beurrier P, Cussac V, Feugeas O, Pailler Y, Callegarin A, Trossaërt M, de Raucourt E. Efficacy and safety of a recombinant Von Willebrand Factor treatment in patients with inherited Von Willebrand Disease requiring surgical procedures. Haemophilia 2021; 27:270-276. [PMID: 33550648 DOI: 10.1111/hae.14242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Von Willebrand Disease is a common inherited haemorrhagic disorder due to a deficiency of Von Willebrand Factor (VWF). In case of surgical procedures in patients who are not responsive or have contraindications to desmopressin, replacement therapy with VWF concentrates is indicated. Until recently, only plasma-derived VWF concentrates were available. A new recombinant VWF (rVWF) concentrate that contains no Factor VIII (FVIII) but a high amount of high molecular weight VWF multimers has been available in France since 2018. AIM Describe real-world experience of using rVWF in surgical procedures. METHODS Sixty-three surgeries for 55 patients were retrospectively analysed in 7 French haemostasis centres. RESULTS During minor surgeries, the median (range) number of infusions was 1 (1-8) with a preoperative loading dose of 35 (19-56) rVWF IU/kg and a total median dose of 37.5 IU (12-288). During major surgeries, the median (range) number of infusions was only 3 (1-14) with a median preoperative loading dose of 36 IU (12-51) rVWF IU/kg, and a total median dose of 108 IU (22-340) rVWF IU/kg. The overall clinical efficacy was qualified as excellent/good in 61 of the procedures (97%), moderate in 1 (1.5%) and poor in 1 (1.5%). There was no accumulation of VWF or FVIII during postoperative monitoring. No thromboembolic events, anti-VWF antibodies or adverse events were reported. CONCLUSION This French 'real-world' experience shows that a few infusions and low doses of rVWF provided effective prevention of bleeding in major and minor surgeries in inherited VWD, with no clinically significant safety concerns.
Collapse
Affiliation(s)
- Dominique Desprez
- Department of Haemostasis, Strasbourg University Hospital, Strasbourg, France
| | - Nicolas Drillaud
- Department of Haemostasis, Nantes University Hospital, Nantes, France
| | - Claire Flaujac
- Department of Haemostasis, Versailles Hospital, Versailles, France
| | - Fabienne Volot
- Department of Haemostasis, Dijon University Hospital, Dijon, France
| | | | - Philippe Beurrier
- Department of Haemostasis, Angers University Hospital, Angers, France
| | - Vincent Cussac
- Department of Haemostasis, Le Mans Hospital, Le Mans, France
| | - Olivier Feugeas
- Department of Haemostasis, Strasbourg University Hospital, Strasbourg, France
| | - Yoann Pailler
- Department of Haemostasis, Nantes University Hospital, Nantes, France
| | | | - Marc Trossaërt
- Department of Haemostasis, Nantes University Hospital, Nantes, France
| | | |
Collapse
|
38
|
Batsuli G, Zimowski KL, Carroll R, White MH, Woods GM, Meeks SL, Sidonio RF. Successful Perioperative Management of Orthotopic Cardiac Transplantation in a Pediatric Patient With Concurrent Congenital von Willebrand Disease and Acquired von Willebrand Syndrome Using Recombinant von Willebrand Factor. J Cardiothorac Vasc Anesth 2021; 36:724-727. [PMID: 33618961 DOI: 10.1053/j.jvca.2021.01.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 12/31/2020] [Accepted: 01/19/2021] [Indexed: 01/18/2023]
Abstract
Von Willebrand disease (VWD) is the most common bleeding disorder and reportedly affects 1:1,000 of the world's population. There are three subtypes of VWD characterized by a quantitative defect (types 1 and 3 VWD) or a qualitative defect (type 2 VWD). Type 1 VWD results in a partial deficiency of von Willebrand factor (VWF) and affects approximately 75% of individuals with VWD, whereas type 3 VWD results in a severe or complete deficiency of VWF. Individuals with type 2 VWD subtypes (types 2A, 2B, 2M, and 2N VWD) express a dysfunctional VWF protein that has impaired interactions with platelets or factor VIII. The majority of individuals with VWD have mild type 1 VWD and occasionally require bolus infusions of VWF for severe bleeding or major surgery. A subset of patients, especially those with type 2A or 3 VWD, may require more frequent VWF replacement or prophylaxis for refractory bleeding or bleeding prevention, respectively. Acquired von Willebrand syndrome (AVWS) is a rare bleeding disorder that primarily occurs as a result of an underlying disease or other pathologic mechanism. Cases of AVWS associated with heart valve defects, left ventricular assist devices, or congenital cardiac disease result from high shear stress in the circulation that induces VWF unfolding and subsequent proteolysis of high-molecular-weight multimers by ADAMTS-13. In rare instances, plasma-derived factor VIII-containing VWF concentrates have been administered to individuals with AVWS for persistent or challenging bleeding events. In this case report, the hemostatic challenges and the perioperative management of cardiac transplantation surgery using a novel recombinant VWF product in a pediatric patient diagnosed with AVWS concomitant with congenital type 1 VWD are described. Written informed consent was obtained from the patient's mother for this case report. The diagnosis of congenital VWD remains a challenge because of multiple potential modifiers that can alter VWF laboratory results. Concurrent conditions, such as congenital heart disease and the rare secondary condition of AVWS, in addition to congenital VWD, can further affect interpretation of coagulation studies. This can result in delays in diagnosis, increase severity of the bleeding phenotype, and complicate hemostatic management in individuals at risk for bleeding and thrombosis. A multidisciplinary approach, including anesthesiologists, cardiologists, cardiovascular surgeons, hematologists, and pharmacists, is critical to achieving optimal patient outcomes, as highlighted in this case report. As diagnostic capabilities and understanding of VWD broaden, future studies evaluating alternative treatment approaches for individuals with various types of VWD would be of great benefit to the medical community.
Collapse
Affiliation(s)
- Glaivy Batsuli
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, GA; Department of Pediatrics, Emory University, Atlanta, GA.
| | - Karen L Zimowski
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, GA; Department of Pediatrics, Emory University, Atlanta, GA
| | - Rachel Carroll
- Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, GA
| | - Michael H White
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, GA; Department of Pediatrics, Emory University, Atlanta, GA
| | - Gary M Woods
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, GA; Department of Pediatrics, Emory University, Atlanta, GA
| | - Shannon L Meeks
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, GA; Department of Pediatrics, Emory University, Atlanta, GA
| | - Robert F Sidonio
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, GA; Department of Pediatrics, Emory University, Atlanta, GA
| |
Collapse
|
39
|
Emerging mechanisms to modulate VWF release from endothelial cells. Int J Biochem Cell Biol 2020; 131:105900. [PMID: 33301925 DOI: 10.1016/j.biocel.2020.105900] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/13/2020] [Accepted: 11/25/2020] [Indexed: 02/06/2023]
Abstract
Agonist-mediated exocytosis of Weibel-Palade bodies underpins the endothelium's ability to respond to injury or infection. Much of this important response is mediated by the major constituent of Weibel-Palade bodies: the ultra-large glycoprotein von Willebrand factor. Upon regulated WPB exocytosis, von Willebrand factor multimers unfurl into long, platelet-catching 'strings' which instigate the pro-haemostatic response. Accordingly, excessive levels of VWF are associated with thrombotic pathologies, including myocardial infarction and ischaemic stroke. Failure to appropriately cleave von Willebrand Factor strings results in thrombotic thrombocytopenic purpura, a life-threatening pathology characterised by tissue ischaemia and multiple microvascular occlusions. Historically, treatment of thrombotic thrombocytopenic purpura has relied heavily on plasma exchange therapy. However, the demonstrated efficacy of Rituximab and Caplacizumab in the treatment of acquired thrombotic thrombocytopenic purpura highlights how insights into pathophysiology can improve treatment options for von Willebrand factor-related disease. Directly limiting von Willebrand factor release from Weibel-Palade bodies has the potential as a therapeutic for cardiovascular disease. Cell biologists aim to map the WPB biogenesis and secretory pathways in order to find novel ways to control von Willebrand factor release. Emerging paradigms include the modulation of Weibel-Palade body size, trafficking and mechanism of fusion. This review focuses on the promise, progress and challenges of targeting Weibel-Palade bodies as a means to inhibit von Willebrand factor release from endothelial cells.
Collapse
|
40
|
Castaman G. How I treat von Willebrand disease. Thromb Res 2020; 196:618-625. [DOI: 10.1016/j.thromres.2020.07.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 01/17/2023]
|
41
|
Yaoi H, Shida Y, Kitazawa T, Shima M, Nogami K. Activated factor VIII-mimicking effect by emicizumab on thrombus formation in type 2N von Willebrand disease under high shear flow conditions. Thromb Res 2020; 198:7-16. [PMID: 33248318 DOI: 10.1016/j.thromres.2020.11.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/24/2020] [Accepted: 11/19/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Type 2N von Willebrand disease (2NVWD) is characterized by a mild to moderate reduction in plasma levels of factor (F)VIII associated with defective binding of von Willebrand factor (VWF) to FVIII and accelerated proteolysis and clearance of FVIII. The clinical phenotype in 2NVWD is often indistinguishable from mild/moderate hemophilia (H)A. Emicizumab is a bispecific antibody to FIX/FIXa and FX/FXa that mimics FVIIIa cofactor function, and emicizumab prophylaxis significantly reduces bleeding events in patients with severe HA. AIM We investigated the potential benefits of emicizumab in the hemostatic management of 2NVWD. PATIENTS/METHODS Perfusion chamber experiments were performed using whole blood from three 2NVWD patients with different clinical phenotypes (bleeding scores: 0, 6 and 20; mutations: p.R816W, p.R816W, and p.R365X/p.T791M, respectively). Furthermore, the impact of specific FVIII-VWF interactions on thrombus formation was investigated. RESULTS Defective thrombus formation that correlated with bleeding phenotype was evident in these 2NVWD patients. Emicizumab improved surface coverage and thrombus height in all cases. Multi-color immunostaining of thrombi further demonstrated that emicizumab enhanced thrombin generation and fibrin formation. The addition of FVIII alone to 2NVWD whole blood did not augment thrombus formation, while supplementation with FVIII/VWF complex enhanced platelet-fibrin interactions. Furthermore, an anti-FVIII monoclonal antibody known to interrupt the release of FVIIIa from VWF depressed these effects. CONCLUSIONS Emicizumab-induced enhancing effects of thrombus formation, independent on VWF, might be useful as an alternative therapy for 2NVWD patients. The extent of FVIII-VWF interaction should be optimal to deliver and release FVIII/FVIIIa on the activated platelet surface.
Collapse
Affiliation(s)
- Hiroaki Yaoi
- Dept. Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Yasuaki Shida
- Dept. Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Takehisa Kitazawa
- Chugai Pharmaceutical Co., Research Division, Gotemba, Shizuoka, Japan
| | - Midori Shima
- Dept. Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Dept. Pediatrics, Nara Medical University, Kashihara, Nara, Japan.
| |
Collapse
|
42
|
Tosetto A, Badiee Z, Baghaipour MR, Baronciani L, Battle J, Berntorp E, Bodó I, Budde U, Castaman G, Eikenboom JCJ, Eshghi P, Ettorre C, Goodeve A, Goudemand J, Hay CRM, Hoorfar H, Karimi M, Keikhaei B, Lassila R, Leebeek FWG, Lopez Fernandez MF, Mannucci PM, Mazzucconi MG, Morfini M, Oldenburg J, Peake I, Parra Lòpez R, Peyvandi F, Schneppenheim R, Tiede A, Toogeh G, Trossaert M, Zekavat O, Zetterberg EMK, Federici AB. Bleeding symptoms in patients diagnosed as type 3 von Willebrand disease: Results from 3WINTERS-IPS, an international and collaborative cross-sectional study. J Thromb Haemost 2020; 18:2145-2154. [PMID: 32379400 DOI: 10.1111/jth.14886] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/09/2020] [Accepted: 04/28/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Type 3 von Willebrand's disease (VWD) patients present markedly reduced levels of von Willebrand factor and factor VIII. Because of its rarity, the bleeding phenotype of type 3 VWD is poorly described, as compared to type 1 VWD. AIMS To evaluate the frequency and the severity of bleeding symptoms across age and sex groups in type 3 patients and to compare these with those observed in type 1 VWD patients to investigate any possible clustering of bleeding symptoms within type 3 patients. METHODS We compared the bleeding phenotype and computed the bleeding score (BS) using the MCMDM-1VWD bleeding questionnaire in patients enrolled in the 3WINTERS-IPS and MCMDM-1VWD studies. RESULTS In 223 unrelated type 3 VWD patients, both the BS and the number of clinically relevant bleeding symptoms were increased in type 3 as compared to type 1 VWD patients (15 versus 6 and 5 versus 3). Intracranial bleeding, oral cavity, hemarthroses, and deep hematomas were at least five-fold over-represented in type 3 VWD. A more severe bleeding phenotype was evident in patients having von Willebrand factor antigen levels < 20 IU/dL at diagnosis in the two merged cohorts. In type 3 patients, there was an apparent clustering of hemarthrosis with gastrointestinal bleeding and epistaxis, whereas bleeding after surgery or tooth extraction clusters with oral bleeding and menorrhagia. CONCLUSIONS In the largest cohort of type 3 VWD patients, we were able to describe a distinct clinical phenotype that is associated with the presence of a more severe hemostatic defect.
Collapse
Affiliation(s)
- Alberto Tosetto
- Hemophilia and Thrombosis Center, Hematology Department, San Bortolo Hospital, Vicenza, Italy
| | - Zahra Badiee
- Hemophilia-Thalassemia Center, Mashhad University of Medical Science, Mashad, Islamic Republic of Iran
| | | | - Luciano Baronciani
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Fondazione Luigi Villa, Milan, Italy
| | - Javier Battle
- Complejo Hospitalario Universitario de A Coruña-Servicio de Hematología y Hemoterapia, A Coruña, Spain
| | | | - Imre Bodó
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | | | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Jeroen C J Eikenboom
- Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Peyman Eshghi
- Pediatric Congenital Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Cosimo Ettorre
- Hemostasis and Thrombosis Center, Azienda Ospedaliera Policlinico Consorziale, Bari, Italy
| | | | - Jenny Goudemand
- Department of Haematology Transfusion, University Lille-CRMW, CHRU Lille, Lille, France
| | | | - Hamid Hoorfar
- Hemophilia Center-Esfahan University of Medical Science, Esfahan, Islamic Republic of Iran
| | - Mehran Karimi
- Hematology Research Center, Nemazee Hospital, Shiraz University of Medical Science, Shiraz, Islamic Republic of Iran
| | - Bijan Keikhaei
- Thalassemia and Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Riitta Lassila
- Coagulation Disorders, Helsinki University Central Hospital, Helsinki, Finland
| | | | | | - Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Fondazione Luigi Villa, Milan, Italy
| | | | - Massimo Morfini
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University of Bonn, Bonn, Germany
| | - Ian Peake
- University of Sheffield, Sheffield, UK
| | - Rafael Parra Lòpez
- Unidad de Hemofilia-Hospital Universitari General Vall d'Hebron, Barcelona, Spain
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Fondazione Luigi Villa, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Reinhard Schneppenheim
- Department of Pediatric Hematology and Oncology, University Medical Centre, Hamburg, Germany
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Gholamreza Toogeh
- Thrombosis Hemostasis Research Center-Vali-Asr Hospital-Emam Khameini Complex Hospital, Tehran University of Medical Science, Tehran, Islamic Republic of Iran
| | - Marc Trossaert
- Centre Régional de Traitement de l'Hémophilie-Laboratoire d'Hématologie, Nantes, France
| | - Omidreza Zekavat
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Islamic Republic of Iran
| | | | - Augusto B Federici
- Hematology and Transfusion Medicine, Department of Oncology and Oncohematology, L. Sacco University Hospital, University of Milan, Milano, Italy
| |
Collapse
|
43
|
Abstract
The management of von Willebrand disease (VWD) is based upon the dual correction of the primary hemostasis defect, due to the inherited deficiency of von Willebrand factor (VWF), and of the secondary defect of factor VIII coagulant activity (FVIII:C), due to the loss of binding and stabilization by VWF of this intrinsic coagulation factor in flowing blood. The traditional therapeutic weapons (the synthetic derivative of the antidiuretic hormone desmopressin and plasma-derived VWF/FVIII concentrates) are able to transiently correct both the defects. With the goal of tackling the primary deficiency in the disease, that is, VWF, but at the same time exploiting the normal capacity of patients to produce FVIII, the novel approach of replacing only VWF was implemented in the last 10 years. Following the manufacturing of a concentrate fractionated from human plasma and of one obtained by recombinant DNA technology, clinical studies have shown that VWF-only products correct not only the primary VWF deficiency but also the secondary FVIII:C deficiency. The demonstrated efficacy of these products in various clinical situations and, ultimately, in such a hemostasis-challenging context as surgery testifies to the effectiveness and safety of this approach. It remains to be seen whether VWF-only products are efficacious and safe in still-unexplored situations, such as use in children; the long-term use for prophylaxis; and in recurrent gastrointestinal (GI) bleeding due to angiodysplasia, a major therapeutic problem in VWD.
Collapse
|
44
|
de Jager NCB, Heijdra JM, Kieboom Q, Kruip MJHA, Leebeek FWG, Cnossen MH, Mathôt RAA. Population Pharmacokinetic Modeling of von Willebrand Factor Activity in von Willebrand Disease Patients after Desmopressin Administration. Thromb Haemost 2020; 120:1407-1416. [PMID: 32746466 DOI: 10.1055/s-0040-1714349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Most von Willebrand disease (VWD) patients can be treated with desmopressin during bleeding or surgery. Large interpatient variability is observed in von Willebrand factor (VWF) activity levels after desmopressin administration. The aim of this study was to develop a pharmacokinetic (PK) model to describe, quantify, and explain this variability. METHODS Patients with either VWD or low VWF, receiving an intravenous desmopressin test dose of 0.3 µg kg-1, were included. A PK model was derived on the basis of the individual time profiles of VWF activity. Since no VWF was administered, the VWF dose was arbitrarily set to unity. Interpatient variability in bioavailability (F), volume of distribution (V), and clearance (Cl) was estimated. RESULTS The PK model was developed using 951 VWF activity level measurements from 207 patients diagnosed with a VWD type. Median age was 28 years (range: 5-76), median predose VWF activity was 0.37 IU/mL (range: 0.06-1.13), and median VWF activity response at peak level was 0.64 IU/mL (range: 0.04-4.04). The observed PK profiles were best described using a one-compartment model with allometric scaling. While F increased with age, Cl was dependent on VWD type and sex. Inclusion resulted in a drop in interpatient variability in F and Cl of 81.7 to 60.5% and 92.8 to 76.5%, respectively. CONCLUSION A PK model was developed, describing VWF activity versus time profile after desmopressin administration in patients with VWD or low VWF. Interpatient variability in response was quantified and partially explained. This model is a starting point toward more accurate prediction of desmopressin dosing effects in VWD.
Collapse
Affiliation(s)
- Nico C B de Jager
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jessica M Heijdra
- Department of Paediatric Haematology, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Quincy Kieboom
- Department of Paediatric Haematology, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Marjon H Cnossen
- Department of Paediatric Haematology, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ron A A Mathôt
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | |
Collapse
|
45
|
Goudemand J, Bridey F, Claeyssens S, Itzhar‐Baïkian N, Harroche A, Desprez D, Négrier C, Chamouni P, Chambost H, Henriet C, Susen S, Borel‐Derlon A. Management of von Willebrand disease with a factor VIII-poor von Willebrand factor concentrate: Results from a prospective observational post-marketing study. J Thromb Haemost 2020; 18:1922-1933. [PMID: 32445594 PMCID: PMC7496521 DOI: 10.1111/jth.14928] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 05/05/2020] [Accepted: 05/14/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND A triple-secured plasma-derived von Willebrand factor (pdVWF) almost devoid of factor VIII (FVIII):WILFACTIN® , was approved in France in 2003, and then in other countries for the treatment of patients with von Willebrand disease (VWD). OBJECTIVE To investigate long-term safety and efficacy of the product in real-life over the first 5 post-approval years. PATIENTS/METHODS This prospective, observational, national post-marketing study (PMS) enrolled patients of all ages and VWD types. Patients were observed for up to 3 years and treated for one or more occasions. Efficacy was assessed for each major event. Breakthrough bleeding rate 3 days post-infusion and annualized bleeding rate (ABR) were also evaluated for long-term prophylaxis. RESULTS Overall, 155 of 174 patients enrolled from 31 centers were eligible for efficacy assessment. Most patients (76.8%) were severely affected (VWF:RCo ≤ 15 IU/dL). They were treated for 743 bleeds and 140 surgeries including childbirth. Efficacy outcomes were excellent/good for 98.2% of 56 major surgeries and 94.0% of 67 major bleeds. Approximately 75% of 49 major mucosal bleeds were effectively managed without FVIII co-administration. In 32 patients receiving prophylaxis, breakthrough bleeding occurred in 1.5% of infusions and median ABR was 1.0 for 20 patients treated ≥ 12 months. Excellent tolerability was confirmed with no safety concerns. No thrombotic events were observed. CONCLUSIONS Results from this PMS increase the clinical experience of a FVIII-poor pdVWF in patients of all ages and VWD types including those with thrombotic risk factors and emphasize that giving FVIII is not always mandatory to effectively treat patients with severe VWD.
Collapse
Affiliation(s)
- Jenny Goudemand
- Department of Hemostasis and TransfusionLille University HospitalLilleFrance
| | - Françoise Bridey
- Clinical DevelopmentLaboratoire français du Fractionnement et des Biotechnologies (LFB)Les UlisFrance
| | - Ségolène Claeyssens
- Centre de Ressources et CompétencesMaladies Hémorragiques ConstitutionnellesCRC MHC URMPurpan HospitalToulouseFrance
| | | | | | - Dominique Desprez
- Centre de compétences trouble de l’hémostaseHopital de HautepierreStrasbourgFrance
| | - Claude Négrier
- Hematology DivisionHemophilia Comprehensive Care CenterLouis Pradel HospitalUniversity Lyon1BronFrance
| | | | - Hervé Chambost
- APHM Centre for Bleeding DisordersLa Timone Children Hospital and Aix‐Marseille UniversityINRAInsermMarseilleFrance
| | - Céline Henriet
- Clinical DevelopmentLaboratoire français du Fractionnement et des Biotechnologies (LFB)Les UlisFrance
| | - Sophie Susen
- Department of Hemostasis and TransfusionLille University HospitalLilleFrance
- EGIDINSERMInstitut Pasteur de LilleUniversity of LilleLilleFrance
| | | |
Collapse
|
46
|
Laffan M, Sathar J, Johnsen JM. von Willebrand disease: Diagnosis and treatment, treatment of women, and genomic approach to diagnosis. Haemophilia 2020; 27 Suppl 3:66-74. [PMID: 32578345 DOI: 10.1111/hae.14050] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/03/2020] [Accepted: 05/11/2020] [Indexed: 01/08/2023]
Abstract
von Willebrand disease (VWD) is the most common inherited bleeding disorder. VWD is caused by deficiencies in von Willebrand factor (VWF), a critical adhesive haemostatic protein. This review provides an overview of VWD diagnosis and treatment, special considerations in treating women with VWD, and current genomic approaches to VWD. For diagnosis and treatment in VWD, an accurate diagnosis is critical to providing effective treatments, determining appropriate laboratory monitoring and for counselling the patient and family. Diagnosis of VWD begins with the clinical assessment for the bleeding phenotype, which is usually characterized by mucocutaneous and provoked bleeding. The diagnosis of VWD is then made by laboratory investigation. Multiple assays are used to assess VWF levels and functions. The mainstays of VWD treatment are tailored by VWD type and symptoms, and can include antifibrinolytic treatment, desmopressin and VWF replacement treatment. Women with VWD are also at risk for excessive uterine bleeding, such as with menses and childbirth. In addition to standard VWD treatments, heavy menstrual bleeding can be treated with hormones. Interdisciplinary management of childbirth and prophylaxis in the postpartum period are needed to reduce the risk of postpartum haemorrhage. Genomic approaches to VWD can inform VWD diagnosis, treatment, test assay selection, reproductive planning and family counselling. Most VWD patients have an identifiable VWF gene DNA variant. Next-generation sequencing is rapidly being adopted to provide more comprehensive VWF sequence information for patients with known or suspected VWD.
Collapse
Affiliation(s)
- Michael Laffan
- Centre for Haematology, Imperial College London, London, UK
| | - Jameela Sathar
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia.,Clinical Trial Unit, Clinical Research Centre, Ministry of Health, Ampang, Selangor, Malaysia
| | - Jill M Johnsen
- Research Institute, Bloodworks Northwest, Seattle, WA, USA.,Washington Center for Bleeding Disorders, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
47
|
Fogarty H, Doherty D, O'Donnell JS. New developments in von Willebrand disease. Br J Haematol 2020; 191:329-339. [PMID: 32394456 DOI: 10.1111/bjh.16681] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 12/19/2022]
Abstract
Von Willebrand disease (VWD) constitutes the most common inherited human bleeding disorder. It is associated with a mucocutaneous bleeding phenotype that can significantly impact upon quality of life. Despite its prevalence and associated morbidity, the diagnosis and subclassification of VWD continue to pose significant clinical challenges. This is in part attributable to the fact that plasma von Willebrand factor (VWF) levels vary over a wide range in the normal population, together with the multiple different physiological functions played by VWF in vivo. Over recent years, substantial progress has been achieved in elucidating the biological roles of VWF. Significant advances have also been made into defining the pathophysiological mechanisms underpinning both quantitative and qualitative VWD. In particular, several new laboratory assays have been developed that enable more precise assessment of specific aspects of VWF activity. In the present review, we discuss these recent developments in the field of VWD diagnosis, and consider how these advances can impact upon clinical diagnostic algorithms for use in routine clinical practice. In addition, we review some important recent advances pertaining to the various treatment options available for managing patients with VWD.
Collapse
Affiliation(s)
- Helen Fogarty
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Dearbhla Doherty
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Coagulation Centre, St James's Hospital, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
| |
Collapse
|
48
|
Vonicog alfa for the management of von Willebrand disease: a comprehensive review and single-center experience. J Thromb Thrombolysis 2020; 49:431-440. [DOI: 10.1007/s11239-019-02018-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
49
|
Garcia J, Flood VH, Haberichter SL, Fahs SA, Mattson JG, Geurts AM, Zogg M, Weiler H, Shi Q, Montgomery RR. A rat model of severe VWD by elimination of the VWF gene using CRISPR/Cas9. Res Pract Thromb Haemost 2020; 4:64-71. [PMID: 31989086 PMCID: PMC6971331 DOI: 10.1002/rth2.12280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/02/2019] [Accepted: 10/06/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Von Willebrand Disease (VWD) is the most common inherited bleeding disorder, caused by quantitative and qualitative changes in von Willebrand factor (VWF). The biology of VWD, studied in canine, porcine, and murine models, differ in species-specific biology of VWF and the amenability to experimental manipulations such as phlebotomy. The factor VIII (FVIII) levels in these models are higher than in humans with type 3 VWD, suggesting functional differences between FVIII and VWF.ObjectivesTo develop a VWF knock out (VWF-/-) rat by excision of all 52 exons of the VWF locus. METHODS The entire VWF gene was eliminated in Sprague-Dawley (Crl:SD) rats via CRISPR/Cas9-mediated gene editing. VWF antigen (VWF:Ag), VWF propeptide, and VWF collagen IV binding (VWF:CB4) levels were determined by ELISA assays and FVIII chromogenic activity (FVIII:C) levels by chromogenic FVIII assays. Lateral tail veins were transected to measure bleeding time. VWF-/- rats were infused with FVIII-/- rat platelet poor plasma (PPP) to determine response of plasma FVIII. RESULTS Breeding of VWF ± rats yielded VWF-/- offspring at normal Mendelian ratios. VWF:Ag, VWF propeptide, VWF:CB4, and FVIII:C plasma levels were undetectable in VWF-/- rats. VWF-/- rats bled longer and more than VWF+/- and VWF+/+ rats when challenged. Transfusion of FVIII-deficient platelet-poor plasma induced a rapid rise in endogenous FVIII:C in VWF-/- rats. CONCLUSION This rat model of severe VWD due to elimination of the entire VWF gene recapitulates the severe secondary deficiency of FVIII seen in human type 3 VWD and facilitates the study of VWF and FVIII and their interactions.
Collapse
Affiliation(s)
- Jessica Garcia
- Department of PediatricsDivision of Hematology/OncologyUT Southwestern Medical CenterDallasTXUSA
| | - Veronica H. Flood
- Department of PediatricsDivision of Hematology/OncologyMedical College of WisconsinMilwaukeeWIUSA
- Blood Research InstituteBloodCenter of WisconsinMilwaukeeWIUSA
| | | | - Scot A. Fahs
- Blood Research InstituteBloodCenter of WisconsinMilwaukeeWIUSA
| | | | - Aron M. Geurts
- Blood Research InstituteBloodCenter of WisconsinMilwaukeeWIUSA
| | - Mark Zogg
- Department of PhysiologyMedical College of WisconsinMilwaukeeWIUSA
| | - Hartmut Weiler
- Blood Research InstituteBloodCenter of WisconsinMilwaukeeWIUSA
| | - Qizhen Shi
- Department of PediatricsDivision of Hematology/OncologyMedical College of WisconsinMilwaukeeWIUSA
- Blood Research InstituteBloodCenter of WisconsinMilwaukeeWIUSA
| | - Robert R. Montgomery
- Department of PediatricsDivision of Hematology/OncologyMedical College of WisconsinMilwaukeeWIUSA
- Blood Research InstituteBloodCenter of WisconsinMilwaukeeWIUSA
| |
Collapse
|
50
|
O'Donnell JS, Lavin M. Perioperative management of patients with von Willebrand disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:604-609. [PMID: 31808837 PMCID: PMC6913501 DOI: 10.1182/hematology.2019000065] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Surgical procedures represent a serious hemostatic challenge for patients with von Willebrand disease (VWD), and careful perioperative management is required to minimize bleeding risk. Risk stratification includes not only the nature of the surgery to be performed but the baseline plasma von Willebrand factor (VWF) levels, bleeding history, and responses to previous challenges. Baseline bleeding scores (BSs) may assist in identification of patients with a higher risk of postsurgical bleeding. There remains a lack of consensus between best practice guidelines as to the therapeutic target and assays to be monitored in the postoperative period. Hemostatic levels are maintained until bleeding risk abates: usually 3 to 5 days for minor procedures and 7 to 14 days for major surgery. Hemostatic supplementation is more complex in VWD than in other bleeding disorders owing to the combined but variable deficiency of both plasma VWF and factor VIII (FVIII) levels. For emergency surgery, coadministration of VWF and FVIII is required to ensure hemostasis; however, for elective procedures, early infusion of VWF replacement therapy will stabilize endogenous FVIII. Because endogenous FVIII production is unaffected in patients with VWD, repeated VWF supplementation (particularly with plasma-derived FVIII-containing products) may lead to accumulation of FVIII. Frequent monitoring of plasma levels and access to hemostatic testing are, therefore, essential for patients undergoing major surgery, particularly with more severe forms of VWD.
Collapse
Affiliation(s)
- James S O'Donnell
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland; and
- National Coagulation Centre, St. James' Hospital, Dublin, Ireland
| | - Michelle Lavin
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland; and
- National Coagulation Centre, St. James' Hospital, Dublin, Ireland
| |
Collapse
|